The lid to an underground city septic tank where a 3-year-old boy drowned last October was not properly secured the day he fell in, according to an investigative report from the Jacksonville Sheriff's Office.
The report, which is more than 340 pages long and includes graphic photos, also indicated that a childproof screw should have been used on the lid, but wasn't.
The I-TEAM has been following the investigation since Amari Harley was reported missing Oct. 22 from Bruce Park in Arlington, where he was attending a birthday party with his family.
The report said Amari and his 6-year-old brother were playing football when Amari said he was tired and left the game. His family realized he was missing less than an hour later when it started to rain and everyone rain for cover.
Amari was nowhere to be found.
The rain stopped after about 10 minutes and the family searched for a half-hour around the park before calling police, according to the report.
While searching for Amari, an officer spotted a pair of underground storage tanks with green plastic manhole-size lids near the park's restrooms. A handle had been pulled up on one of the lids, and the officer reported that neither lid was secured to the tanks.
IMAGES: Amari Harley evidence photos
“A small child could easily have removed them,” the officer reported.
Police later called in a pump truck to remove the 4,000 gallons of liquid in the 8-foot-deep tank, and about halfway through pumping, a child's shoe was spotted in the tank.
They found Amari's body not long after.
Stuffed animals piled in a memorial to the little boy can still be seen near the tanks, nearly five months later.
The Medical Examiner ruled Amari's death an accidental drowning.
The I-TEAM previously reported that in the year before Amari died at least two complaints had been filed with the city, regarding the lids not being properly secured on the park's two tanks.
During its investigation into how Amari was able to fall into the tank, JSO learned that a third incident had been found by the man who inspected the park's tanks for a contractor.
John Kuhn admitted that during his inspection on Sept. 12, just over a month before Amari drowned, he found the lids were not on the tanks, and he had to secure them with screws.
Investigators asked Kuhn about lettering on the green lid, indicating the need for a “childproof screw.”
He said that would indicate a screw requiring a special tool to remove it should be used in that area.
But he admitted no such screw was used, and he didn't recall ever taking steps to address childproofing the lid, according to the report.
Amari's family has filed a wrongful death lawsuit against the contractors tasked with maintaining the sewage tanks, arguing they were negligent.
The family's attorney, Kay Harper Williams, said that over a year’s period the lid was reported as being unsecured six times. She that is unbelievable and she intends to also sue the city.
"For about $1,200, the city could have saved Amari Harley," Williams said. "That is what we’re talking about here. It is the level of gross negligence -- the countless opportunities to remedy a clear and obvious wrong, a clear and obvious danger."
Amari's loved ones declined to comment about the JSO investigative report.
News4Jax also contacted the city to see if officials had any reaction to the final report or any update on the process of standardizing the lids at 76 parks and boat ramps across the city. Mayor Lenny Curry promised last year that would be done in the wake of Amari's death.
To date, 193 covers around the city have been replaced with heavy, iron lids that are bolted into place, including the lids where Amari died.
"Those lids are going to be the standard lids for all locations when they are all complete," said Erik Engstrom of the city's Public Works Department. "Any septic tank is going to have those lids on it."
But Williams said the changes after the fact are little comfort to Amari's family.
"I think all of this is too little, too late," Williams said.
The I-TEAM reported last November that the septic pumps in the tanks at Bruce Park needed to be replaced. That worked appeared to be happening Monday morning.
The I-TEAM has also learned that a city employee whose job it was to monitor septic tank inspections has been disciplined and no longer oversees that area. Inspections are now being done in house and not by hired contractors.
Williams also told News4Jax on Monday that she will be asking the State Attorney why no criminal charges have been brought against those responsible for Amari's death.